The Association of American Medical Colleges (AAMC) was founded in 1876, a non-profit focused on "transforming health through medical education." Its members include "172 ... medical schools, 490 teaching hospitals and health systems," and over "70 medical societies."
For reference, "There are currently 160 allopathic (MD) medical schools and 42 osteopathic (DO) medical schools in the US." Thus, the only actual path to becoming a physician is through the AAMC process. And while there "are nearly 1,700 teaching hospitals," only "300 are considered to be major teaching hospitals." In short, the AAMC controls many and perhaps most medical students.
The AAMC describes the residency process as an application activity followed by "interviewing at the programs that offer you an invitation." So, across the country, medical students enter this process and build a portfolio of applications, curriculum vitae, recommendation letters, transcripts, and more that is reviewed by those in which that student has an interest.
In the residency process, the National Resident Matching Program (NRMP) is engaged. There is agreement required for medical students to enter this program, which "ensures that participants, applicants (sic) and program directors in particular, understand their rights and responsibilities."
Thus, despite the vast population of controlled schools, students, and programs, a student could elect to go it alone. While an actual alternative, one wonders if it is in any way a realistic alternative. Can a student get a residency as an independent, or is the voluntary nature an illusion?
The National Matching Program is a non-profit to "help ... promote fair and transparent selection processes for applicants and hiring/training groups." Whatever else it is, an effective mandate or not, it is undeniably a program that constrains the free market opportunities of applicants and programs. The process alters the free market and constrains both.
Some see it as violative of the anti-trust provisions of American law. The House of Representatives has begun looking into this market constraint, and recently held hearings. It reportedly concluded that the process is "binding" and noted concerns with the facilitation of sharing information and potentials for impairing negotiation and competitiveness.
The NRMP then "uses a computerized mathematical algorithm, the 'matching algorithm,' to place applicants into the most preferred residency and fellowship positions at programs that also prefer them." Following a 2002 lawsuit, Congress passed an antitrust exemption for this process. It is legal for residency programs to collude with each other to constrain opportunity, compensation, and competition.
Is there any other educational process or system that enforces a singular and systemic path into professional service? Some will take issue with "enforces," but the figures support that there are almost no schools that do not participate and few major residency programs. Further, the "binding" noted by Congress supports the "enforce" adjective.
The Match proponents will nonetheless likely argue that this program is entirely voluntary for schools, students, and residency programs. In 2023, however, the American Medical Association concluded in a resolution (#302) that "The Match poses significant anticompetition concerns." The Sherman Antitrust Act (1890) was mentioned. There was a discussion of better information and access for medical students.
The NRMP says its process "is unique among national medical education organizations," and it has been the subject and study of Nobel-Prize-winning research." In conjunction with placement, "the NRMP began collecting voluntary applicant demographic data in 2021" with an aim "to improve diversity, equity, inclusion, and belonging (DEI-B) in the transition to residency." The report of its Match Summit Meeting in December 2023 stresses this.
The matching process is apparently about DEI - fundamentally so, according to the AAMC and NRMP literature. With the volume of federal money that flows to schools and medical care delivery systems, it may be that recent federal changes could affect the Match.
An aside on Nobel primacy, that is seemingly inferred, is noted. The Nobel is not universally conclusive on any front. There has been ample room to criticize various recipients. Being the "story of Nobel ... research" is no more conclusive of validity or celebrity than graduating from Harvard. Yes, a fair few infamous folks have that honor, see Theodore Kaczynski, Cotton Mather, and others. Association with institution or honoraria is neither necessarily indicative of honor nor accolade.
But, back to the point. The Match process is, to an outsider at least, somewhat involved and complex. Some might assign more critical adjectives.
As I read through various documents and websites, the similarities between modern residency matching and historical college sorority rush came to mind. A little research substantiated that I am not alone, see Sorority Rush as a Two-Sided Matching Mechanism, American Economic Review, vol. 81, June 1991, 441-464. The process is complex, complicated, and frustrating for some. It denies the human tendency to free association and perhaps encourages pure cronyism.
Courtesy http://theboola.com/expect-sorority-rush/
Why would anyone outside of medical education, or sororities, care?
The whole Match topic came to my mind when Jessica Pereira made the national news following "Match Day 2025." The 30-year-old "was heartbroken ... (when) she didn't place into any of her first or second choice surgical programs." Essentially, none of the sororities offered her a bid to be a resident physician. She opened up on social media, which led to articles on platforms like People.
Alicia Chen was similarly disappointed, according to People. She described some reluctance to post about disappointment on social media but explained that she did so to help "future and current students ... not feel so alone." She laments "all these four years you work so hard for, at the end of the tunnel, you actually don't have a job."
In fairness, there are apparently residency programs that are more competitive than others. Each of these doctors sought positions as surgeons, which is reportedly among the more competitive. Not everyone gets into Ball State either, so you know in advance to apply to multiple colleges - just in case. But, again, these applicants did not rush every sorority in medicine, they picked which to rush and those sorority houses did not extend bids.
Is that fair? Does fair matter?
Ms. Chen notes "this was the only type of medicine she wanted to pursue." There is merit in going after what you want. When I graduated from law school, I sent out hundreds of resumes and received only a few interviews and offers. To put it bluntly, I was disregarded by many sororities as I strove for a match without the complications of an organized rush, an algorithm, or a national Nobel-recognized system.
Ms. Periera and Chen's stories are not unique. According to the AMA, the "don't match" rate was 6%-7% depending on MD or DO. Those who don't match can strive for a position through a "Supplemental Offer and Acceptance Program" (SOAP), or can "reapply for the next matching cycle."
You find yourself at graduation, with an average of $243,483 in student debt, and you may have to wait "for the next ... cycle." You can find yourself with such debt and seeking work in a marketplace where employers are free to compare and collude due to exemption from the antitrust constraints applicable to so many others.
Why does any of this matter? The end of the story is that there are some examples of people who did not get what they want. The largest lesson for them is perhaps to widen horizons. But unlike many professionals who have market-driven horizons, the medical graduate is largely confined to the defined process of Match(ing) or SOAPing.
The path to being a doctor is narrow, constrained, and to some extent exempt from the law.
Notably, this matters way beyond Ms. Chen and Ms. Pereira. The AAMC (yes, the same AAMC) reports that we "face a physician shortage of up to 86,000 physicians by 2036." Yes, Virginia, there is a physician shortage today and it is getting worse. Why are we not opening medical schools, expanding residency opportunities, and increasing supply?
The answer is that some new schools have opened this century, 29 MD and 17 DO. Other schools have increased enrolment. More students, more programs, but still the prediction of 86,000 too few physicians. Is enough being done? Why are residency opportunities still constrained?
In economic systems, there are multiple methods for resource distribution. Some are control-driven (Socialism, Communism) and others range toward free markets. Regardless of distribution method, all economic resources in all systems are scarce. Physicians and their time are no different.
Why does any of this matter? Possibly, two physicians were shut out of the market in 2025 (and likely more of the 6%-7% that did not Match). Will they have the fortune to SOAP, or will they find economic and personal peril in waiting for the next cycle? Will they juggle debt and struggle? Will others be disinclined to join the challenging and demanding path to an MD or DO based on the reported experiences at the hands of a discriminatory Sorority rush algorithm?
Is our education process and path part of the solution or part of the problem? Is the market putting all possible stress on the imperative point - more doctors? Better prepared doctors? And, are the best and brightest, the hardest working, getting the best opportunities? Or are the best sorority houses on campus controlling rush with their inside information and the anti-trust exemption?
There is time and reason to question the challenges. In 11 years, we will be 86,000 physicians short. I will be old and will want medical attention. Will I and my peers be able to acquire care? Or will the constraints on competition continue to result in the U.S. having the most expensive medical care in the world?
